Are there any restrictions for travellinbg with HIV meds from south africa to back from Paris and Paris via Dubai to South Africa? If any, how does one deal with them? Thanks

Response from Dr. Frascino

Hi,

See below for travel tips for the "virally enhanced."

Dr. Bob

On the Road With HIV: A Guide for Positive Travelers

By Amelia Glynn

Summer 2007

Introduction

Hooray for summertime! There's something about the longer days and warmer nights that helps bring out the traveler in all of us.
"Traveling has an element of spontaneity and the unknown," says Joni Lavick, MFT. "You never know what can happen." She sees this as potentially a great thing for people who are living with HIV.

Lavick has been working with HIV positive patients since 1988. She has a private practice in Santa Monica and is a clinical supervisor at the L.A. Gay & Lesbian Center. "One of the challenges of being HIV positive is having the resilience to stay on top of it," she says. "It requires a lot of mental-health energy to be able to spring back." She believes travel can play an important role in bolstering this necessary resilience.

When we arrive in a different country, we often have to deal with a different culture, language, climate -- you name it. "We give ourselves credit for achieving the smallest, silliest things when we are traveling," Lavick explains, like reading a map correctly, figuring out a new transportation system to get to the next museum, or just finding our hotel.

Experiencing new things -- and the resourcefulness it requires -- helps us tackle other challenges, including those that are health related. "You know inside yourself that you have the ability to take on new things as they are thrown your way," says Lavick.

So, even though packing your meds, avoiding new infections, and locating medical services away from home might seem overwhelming (especially if it's your first time traveling with HIV), there are lots of good reasons for you to take that trip. Lavick considers it a great opportunity to "get out of your head" and take the focus off of yourself.

Doing your homework and being prepared -- including talking with your doctor, carefully researching your destination, and getting any necessary pre-trip medications -- can help take the anxiety out of traveling so you can relax and enjoy your time away.

Belize or Bust

So, you've decided it's time to take a break from your daily life. You're craving a change of scenery and perspective. Carefully considering what kind of destination, pace, and expense are best for you is essential to planning a healthy and rewarding trip.
At the most basic level, it's important to be honest with yourself about how you're feeling physically and emotionally. Are you up for that six-day white-water rafting adventure with your extended family? In some cases, opting for a more stress-free vacation (such as a cruise or some R&R at an all-inclusive beach resort) may do your mind and body more good.

Brad Hudson, founder of Travel Zone (www.travelzone-sfo.com), says all-inclusive resort vacations and cruises are good for people who don't want the hassle of moving hotels and packing and unpacking. They also afford guaranteed refrigeration for medications. "This a great option when you want to see more than one place without having to plan all the details yourself," he says. Some tour companies cater specifically to the gay and lesbian community, including RSVP Vacations, Atlantis Events, Above and Beyond Tours, Alyson Adventures, Pied Piper Travel, and Toto Tours.

One of Alyson Adventures' most popular tours is a rafting trip down the Colorado River. Even though the location is remote, owner Phillip Sheldon points out that tour guides have a built-in refrigerator: "The river can maintain everything from steak dinners to individual medications." All of the guides are equipped with satellite phones in case of an emergency, but he says there is a certain amount of self-selection involved. "We try to give people a good idea of what the trip is all about and leave it up to them to decide. The nice thing is, because we offer 50 trips a year to 35 countries, everyone can find something that works for them."

Irv, a marketing and sales consultant in Northern California, likes cruises because he can unpack once and visit several places. "The food is great and I get to pay for it all before I leave," he says. "The amenities are great. I never have to worry about having access to a refrigerator." Instead of being drawn to gay cruises, he often prefers to keep company with seniors. "They are the most compassionate people," he says. "When you sit down to dinner, everyone will look you in the eye and introduce themselves. I always have the most stimulating conversations." And if he likes a particular city, he knows he can always go back.

"There's something very therapeutic about being in a place where there is no land for miles," says Irv. "Every time I come back from a cruise, I feel like I've added a year to my life." You needn't stray too far from home, though, to reap the benefits of travel. "I'm not a big fan of flying, and really, it doesn't take a lot of mileage to get some distance from your daily life," says Mary, a San Francisco graphic designer. "On a road trip, I don't have to worry about getting to the airport on time or getting through security with all my stuff. I can throw my meds and my flip flops in a backpack and be on vacation the minute I get in the car!"

An added benefit of local trips or less luxurious getaways is, of course, the lighter burden on your wallet. Lavick says that even many of her patients who are on disability or have fixed incomes find the means to travel -- by taking really cheap flights or using frequent flyer miles and renting inexpensive apartments (equipped with money-saving kitchens) in the off-season. One such client recently spent a month in France. "Travel isn't just for my affluent patients," she says. "Everyone comes back energized and rejuvenated. I see nothing but positive mental benefits from travel."

However you decide to spend your time away -- whether you're surfing the Pacific or your best friend's couch -- remember to listen to your body. You'll get more out of your trip if you stay hydrated, eat well, and take rest when you need it.

You and Your M.D.

The first step that any HIV-positive traveler should take is to evaluate your overall health with a physician, keeping a close eye on your CD4 cell count. If it's below 200 cells/mm3 (which indicates severe immunodeficiency), trips to areas where parasitic, bacterial, and viral diseases are highly prevalent can be risky.
Your physician or travel doctor can offer suggestions about staying healthy on the road and may be able to share names of medical providers who treat HIV in the regions you plan to visit.

Stephen E. Follansbee, M.D., Director of HIV Services and Travel Medicine for Kaiser Permanente San Francisco, encourages travel for his HIV positive patients. "I think it's a good idea and most people can travel safely," he says, with the caveat that their travel plans should be individualized and address any special health considerations and treatment regimens.

"One of the things that scared me when I first found out I was HIV positive was the idea that it might prevent me from traveling," says Ghee, a San Francisco native and avid traveler who was diagnosed in 1995. He sees his doctor regularly and checks in with him before he travels. "I always ask any questions I might have about a future trip I'm planning, but by now I'm pretty versed and secure in the choices I make," he says.

Getting Immunized

When Irv went to India, he got 22 pre-trip shots. "There are a lot of logistics involved when traveling with HIV, but it's worth it," he says.
Ask your physician or travel medicine expert and check the Centers for Disease Control and Prevention (CDC) Web site (see below) for more information regarding specific immunizations that are recommended for the areas you plan to visit. You'll also want to confirm that all of your routine immunizations are up-to-date; this is especially important for children with HIV. In general, all HIV positive travelers are advised to be vaccinated against polio, typhoid, and hepatitis A and B.

On the Web

Consult the CDC's list of recommended immunizations for destinations worldwide

Search the International Society of Travel Medicine's online directory of travelers' health clinics.

Anyone with a CD4 count below 200 cells/mm3 is advised to avoid "live vaccines," such as those for measles and yellow fever. In general, killed-virus vaccines are safer for people with HIV. Some countries require proof of immunization for entry. If Dr. Follansbee is not able to vaccinate one of his patients for health reasons, he provides a letter explaining why his patient has not received the required immunizations (although this precaution does not guarantee that the unvaccinated traveler will be allowed to enter the country).

Dr. Follansbee says it's also important to be aware that certain drugs may interact negatively with HIV medications; for example, malaria prevention drugs may have temporary neurological effects (for example, bizarre, vivid dreams) that compound side effects associated with some antiretrovirals, such as efavirenz (Sustiva). It is always important to talk to your primary care physician and about the pre-trip vaccinations and medications that are right for you.

Travel Tips

Snack Savvy

If you need to take your medications with food, come prepared: whether you're traveling by train, plane, or automobile, pack a few snacks. You'll also want to bring a bottle or two of water (or purchase one once you've passed through airport security).

Jet Setting: Meds and Time Zone Changes

You may need to adjust your medication schedule when you cross into a different time zone. Stephen Follansbee, M.D., suggests waiting 24 hours and then taking your next dose at your normal time, wherever you are. If you are a few hours off it shouldn't make a huge difference, he says. The most important thing is to stick to a regimen that's been working for you.

A seasoned traveler, Irv takes his pills once in the morning and again in the evening. "I'm completely on vacation during the day and don't think about HIV again until night. One thing I've learned about HIV is that it loves attention," he says.

A Medication Vacation?

Although vacations can be a great opportunity to shift your attention beyond your HIV health, many doctors advise against taking a holiday from your meds. Treatment interruptions carry the risk of developing drug-resistance mutations, as well as other health problems (see "Structured Treatment Interruptions: After SMART" in the Summer 2006 issue of BETA).

"I don't typically recommend taking a break from meds," says Dr. Follansbee. "And I definitely don't recommend it for travel. There are too many possible complications." Instead, he works with patients to help streamline their daily dosing schedules and manage their pill burden.

Playing it Safe

Take all of the same precautions you would at home to prevent HIV transmission. Bring a healthy supply of condoms if that's part of your safer sex practice -- they may be harder to find or of inferior quality in some travel spots.

First-Aid Essentials

Even though you may be able to buy many of these items during your trip, the peace of mind of having them at hand can be worth the extra bit of room they take up in your suitcase:

As most people taking anti-HIV meds have learned from experience, no treatment regimen is completely free from side effects. These usually manifest within a few weeks after beginning treatment or making a switch, so it's smart to give yourself a solid month or two before wandering too far from home.
Irv takes 24 prescription pills a day and knows first-hand the importance of adjusting to a new regimen before hitting the road. "All the ads for new HIV medications say things like, 'You can ride bikes, climb mountains,' and I think, 'Are you kidding?' Maybe after you get over the explosive diarrhea and whatever other side effects they have," he says. "Once you start to jive with your medication, that's when I say it's time to get out of Dodge."

Irv has other health issues along with HIV, including a heart condition and diabetes. When he travels, he brings his doctors' contact information, a printout of the results from his most recent viral load test and CD4 cell count, and a list of all of the prescription drugs, over-the-counter medications, and alternative treatments he uses (and their dosages).

If your trip involves flying, pack as much of your medication in your carry-on bag as possible, since there is always a chance your luggage could be lost or delayed. According to the U.S. Transportation Security Administration (TSA) regulations, prescription and non-prescription medications do not need to be packaged in the usual quart-size clear plastic bag. If your medications are in liquid, gel, or aerosol form in containers greater than three ounces, you must declare them at the screening checkpoint (be sure to check the TSA Web site for updates. And if the name on your prescription label does not match the name on your passport or driver's license, be prepared to explain why to a security officer.

It's wise to count out your pills ahead of time, and to bring extras along in case you experience any delays or decide to extend your trip. Alejandra, a counselor for the Oakland-based organization WORLD (Women Organized to Respond to Life Threatening Disease), often travels with double the amount of medication she needs. Depending on how long you plan to be away, you may also want to carry your meds in something other than their original containers (such as zip-top plastic bags) to avoid extra bulk in your luggage -- just be sure to keep a copy of the prescription or the prescription label with you. If any of your medicines come with a desiccant (a drying agent), transfer it to the new container.

If you're carrying any medicines that might be controlled substances (some pain medications, for instance), it's a good idea to keep them in their original containers with your prescription information attached. Carrying a letter from your doctor that states you are taking the drugs for a chronic medical condition can also be helpful. Regardless of where you go, bring a list of your medications, dosages, and dosing schedules, and your doctor's name and phone number. Always be prepared to replace your medicines, just in case. You may want to ask your doctor to give you extra copies of your prescriptions.

If any of your medications are temperature-sensitive, consider storing them in a small, insulated lunch bag with an artificial-ice freezer pack until you get to your destination. And make arrangements for a refrigerator where you'll be staying. "Some medications will retain their efficacy for up to a month at room temperature," says Dr. Follansbee. "Just keep them out of direct sunlight and avoid extreme temperatures." (So, in other words, no driving through the Sahara with your meds on the dashboard.) Always read the manufacturer's guidelines and check with your doctor to confirm your options for storing medications.

HIV and International Travel

Most tourist destinations do not restrict entry to HIV positive visitors who plan to stay for three months or less. Still, there are several countries that may deport or block the entry of positive travelers. If you are planning to travel internationally, do your homework and find out what entry restrictions you may encounter at your destination.
Traveling overseas can be a great opportunity to see the resources that are available to HIV positive people in other areas. "Some of my patients make a special point to visit HIV clinics and organizations when they travel," says Lavick. "It becomes an anchoring point of their trip."

Alejandra is an enthusiastic traveler who has taken several trips to Spain (including two six-month stints). She researched the country's health care system in advance and was confident she would be able to find a clinic where she could be treated and receive her medications if necessary. She encourages other positive travelers to ask their doctors if they have any questions or concerns about emergency treatment abroad.

Irv took a month-long European cruise last October, starting in Istanbul and ending in Barcelona. "These countries were more liberal than I ever imagined," he says. He finds that many countries (such as Turkey, which he calls "the most enlightened" place he's visited so far) are more open and accommodating to HIV positive travelers than is the United States. He recalls that when traveling with an ex-partner who was not an American citizen, going through U.S. customs was the worst part of their trip. "England is also challenging," he says. "It makes me think twice before I travel there."

Ghee recently returned from ten days in Belize. "Seeing other ways of life opens your mind," he says. "I like to get a feel for what other people think of Americans and our politics." He recalls a particularly memorable trip to Guatemala to visit the Mayan ruins of Tecal: "Listening to the tour guides describe this ancient civilization makes you think about your own world. It reminds you that you are not invincible. Everything is temporary."

International Travel (Restrictions May Apply)

The UK-based HIV/AIDS education organization NAM lists entry restrictions for more than 150 countries on their AIDSMap site.

But for the most accurate and current information, call each destination's embassy or consulate and ask -- anonymously.

Eat, Drink, and Be Merry

So much of traveling is about sampling the local cuisine. Having HIV shouldn't prevent you from satiating your inner foodie. You'll just want to take a few extra precautions to keep yourself healthy.
Although the exotic smells from street vendors and outdoor markets may be tempting, it's often best to look rather than taste. Like most foreign travelers -- both HIV positive and negative -- you would be wise to steer clear of raw fruits and vegetables (which may retain unfamiliar microorganisms from soil or water), raw or undercooked seafood or meat (ground meats can be especially risky), and unpasteurized milk and dairy products. According to the CDC, foods that are generally safe include steaming-hot foods and fruits that you peel yourself.

Although eating food from a restaurant is usually your safest bet, be sensible about the foods you choose, especially in hotter climates where certain ingredients -- such as eggs and dairy products -- tend to spoil easily. Dr. Follansbee recalls a time when one of his patients who was visiting Cairo, and on his way to India to see the Taj Mahal, ate an egg-salad sandwich from his hotel restaurant. He ended up in a U.S. military hospital with severe food poisoning and shortly afterwards was on a plane back to the United States. It's better to err on the safe side than risk cutting your trip short.

If you're unsure about the local water supply, drink distilled water or bottled carbonated beverages -- without ice. (A bottle labeled "purified spring water" doesn't necessarily guarantee that it will be clear of Cryptosporidium parvum, one of the most common infecting agents in the severe diarrhea associated with HIV disease.) This is especially important when visiting developing countries where the water supply may contain microorganisms that pose little threat to local residents (who ingest them daily) but wreak havoc on the uninitiated stomachs of foreign visitors. If bottled water is not available, boil your water for at least one full minute before drinking it.

Staying Healthy Abroad

In addition to having HIV, Alejandra also experiences lupus outbreaks. On her very first trip after her diagnosis, she packed "every medicine imaginable" in her travel kit. Now she says she's more relaxed but still plans ahead: "There are many positive things about traveling, but I always take precautions." For example, before visiting Bolivia, she educated herself about altitude sickness so she would be prepared when she arrived. "In general, it's good to know about different sicknesses or conditions that may be associated with the place you're visiting," she advises. "I tend to associate however I'm feeling with my HIV, but sometimes there's a simple explanation that is also very preventable." Alejandra also recommends talking with other travelers about their experiences to learn more about your destination.
Especially before traveling to tropical or subtropical countries, consider consulting a travel medicine specialist. He or she can offer suggestions about staying healthy in places where certain illnesses, such as tuberculosis, may pose special threats to HIV positive visitors. If you're planning to be away for more than a month, it's good practice to look into facilities for treatment of HIV-related problems in your destinations.

Be sure to take extra precautions against insect-borne diseases when visiting destinations where they are a problem. This includes using insect repellent that contains 30% to 40% DEET. (People with sensitive skin may prefer to wear pants and long sleeves and spray insect repellant onto their clothing rather than directly onto the skin.) Many camping-supply stores also carry insect-repelling clothing as well as mosquito nets that are pretreated with the insect repellent permethrin. Sleeping under a mosquito net (which can often be purchased inexpensively in local markets and shops) is highly recommended in areas where malaria or dengue fever is prevalent.

To prevent possible waterborne infections, such as cryptosporidiosis and giardiasis (both caused by microscopic parasites), you may want to avoid swimming in potentially contaminated water, such as rivers, lakes, and streams, and even swimming pools if they are not properly chlorinated. If you do indulge in a dip, be extra careful not to swallow water.

The CDC and most doctors recommend avoiding areas where yellow fever is widespread. Tuberculosis is very common worldwide and can be very serious in people living with HIV; be sure to get tested when you return home.

Medical Care and Insurance

If you're traveling to a remote area or developing country, Hudson (of Travel Zone) recommends calling your medical insurance plan to ask what it covers when you are away from home. Many insurance plans have limited benefits outside the home country. For example, the Medicare/Medicaid program does not cover medical services received abroad. Very few plans cover the cost of flying you home if you become very sick.
"It could be a good idea to supplement your coverage with traveler's insurance," says Hudson. Traveler's insurance generally covers preexisting conditions, as well as MedEvac in case you need to be airlifted to a hospital. (A single uninsured trip in a MedEvac plane can cost thousands of dollars.) Hudson also advises travelers to check with their credit card issuers before buying additional coverage, as some cardholders are entitled to free emergency medical evacuation coverage. Some tour companies, such as Alyson Adventures, automatically provide traveler's insurance (which covers preexisting conditions) for their customers.

Happy Trails

"Whether or not you have the disease, it's up to you how much risk you want to take when you travel," Ghee says. He's gone on more trips in the last five years than ever before. "It's the old cliché -- a blessing in disguise," he says. He still thinks about his mortality, but he has faith in the medications he's taking. "I'm a walking example that they work," he says.
And "getting away" doesn't have to mean getting into debt. "Taking short trips -- road trips, day trips -- can be very healing," says Mary. "I've learned that vacations don't have to be this huge thing you do, with lots of planning and lots of money. Just getting out and enjoying the environment around you can be a true vacation, even if you're only away for a weekend." She's looking forward to heading down the coast with her husband this summer.

Irv is planning his next trip, too: a cruise (of course) to Antarctica and South America. "When I travel, I get excited. I make new friends, have new experiences, and my HIV fades into the background. Every time I get out, I think, 'I'm doing this for David and Frank, and George,'" friends he lost to AIDS. For him, living well while he explores the globe is the best medicine of all.

Amelia Glynn is a freelance writer and former HIV counselor in San Francisco. An activist at heart with a keen interest in health care, she secretly dreams of wearing scrubs.

Kaplan, J. and others. Guidelines for preventing opportunistic infections among HIV-Infected persons -- 2002. Recommendations of the U.S. Public Health Service and the Infectious Diseases Society of America. Morbidity and Mortality Weekly Report 51(RR08):1-46. June 14, 2002.

World Health Organization. International Travel and Health. Geneva: WHO Press. 2007.

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